Implementing an integrated pathway to care for the dying: is your organisation ready?

BACKGROUND: Integrated pathways for care of the dying aim to promote the delivery of high-quality palliative care, regardless of access to specialist services. AIM: To produce a heuristic technique to assist with planning and evaluating the integration of the care of the dying pathway into everyday work. METHODS: Electronic databases were searched to identify research papers focused on the implementation of integrated pathways for care of the dying in acute hospital settings. RESULTS: A total of 13 articles were reviewed using the four elements of normalisation process theory-coherence, cognitive participation, collective action and reflexive monitoring. These results informed the development of a heuristic for organisational readiness. CONCLUSION: The organisational readiness heuristic provides an evidence-based checklist for organisational leaders who are planning to introduce new, or evaluate current, integrated pathways for care of the dying. The next step is to trial the heuristic for feasibility in practice.

Hereditary leiomyomatosis and renal cell cancer (HLRCC): cutaneous and renal manifestations requiring a multidisciplinary team approach.

Cutaneous leiomyomasare rare tumours of smooth muscle origin associated with disorders such as hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome. HLRCC is an autosomal dominant syndrome caused by loss of function mutations in the fumarate hydratase gene. Sufferers of this disorder are predisposed to the development of tumours of the skin and/or uterus, with a further subset of HLRCC families at risk of renal cell carcinoma with papillary features. This syndrome is rare and carries with it a significant rate of mortality. A multidisciplinary approach to care is critical in the management of these patients and their families. The dermatologist can play a central role in this process, coordinating care between specialist medical and allied health teams.

Multidrug-resistant Fusarium keratitis: diagnosis and treatment considerations.

Mycotic keratitis is an ocular infective process derived from any fungal species capable of corneal invasion. Despite its rarity in developed countries, its challenging and elusive diagnosis may result in keratoplasty or enucleation following failed medical management. Filamentous fungi such as Fusarium are often implicated in mycotic keratitis. Bearing greater morbidity than its bacterial counterpart, mycotic keratitis requires early clinical suspicion and initiation of antifungal therapy to prevent devastating consequences. We describe a case of multidrug-resistant mycotic keratitis in a 46-year-old man who continued to decline despite maximal therapy and therapeutic keratoplasty. Finally, enucleation was performed as a means of source control preventing dissemination of a likely untreatable fungal infection into the orbit. Multidrug-resistant Fusarium is rare, and may progress to endophthalmitis. We discuss potential management options which may enhance diagnosis and outcome in this condition.

Validation of a three-frequency bioimpedance spectroscopic method for body composition analysis.

OBJECTIVE: We assessed whether whole-body multiple frequency impedance (MFBIA) data obtained at a few discrete frequencies could be used to estimate accurately resistance at 0 (R(0)) and infinite (R(infinity)) frequencies required for prediction of body composition by mixture theory. METHODS: Fat-free mass (FFM) was measured in 157 subjects (77 males, 80 females; body mass index [BMI] 17.8-41.7 kg/m(2)) by dual X-ray absorptiometry (DXA). Whole-body impedance was measured and R(0) and R(infinity) were calculated by three different methods. FFM predicted using the different values of R(0) and R(infinity) were compared with each other and with the reference DXA values for all subjects stratified according to BMI band (BMI <24.9 kg/m(2), normal weight; BMI 25-29.9 kg/m(2), overweight; BMI >30 kg/m(2), obese). RESULTS: All BIA procedures predicted an FFM that was slightly but significantly different from DXA-derived values, underestimating by 0.24 to 1.4 kg in the normal-weight subjects and overestimating by 5.3 to 7.1 kg in the obese subjects. Although statistically significant, the different impedance procedures were highly correlated (r > 0.98), with small limits of agreement (approximately +/-2%) when used to predict FFM. Predictive power was associated with BMI, worsening as BMI increased. CONCLUSION: MFBIA can be used to estimate impedance parameters required for mixture theory prediction of body composition, but this approach requires adjustment for BMI to be accurate.

Thickened fluids and water absorption in rats and humans.

Individuals with dysphagia are commonly provided with oral fluids thickened to prevent aspiration. Most thickening agents are either gum-based (guar or xanthan) or are derived from modified starches. There is evidence, predominantly anecdotal, that dysphagic individuals are subclinically dehydrated. Dysphagia has a particular impact on elderly individuals and there is justifiable concern for dehydration in this population. It has been speculated that dehydration may, in part, be the result of the water-holding capacity of these thickening agents decreasing water absorption from the gut. The aim of this study was to determine the rate of intestinal absorption of water from thickened fluids. The method used was a laboratory tracer study in rats and humans in vivo. We found that there were no significant differences in water absorption rates between thickened fluids or pure water irrespective of thickener type (modified maize starch, guar gum, or xanthan gum). These data provide no support for the view that the addition of thickening agents, irrespective of type, to orally ingested fluids significantly alters the absorption rate of water from the gut.